Lady Cycles

Cut through the confusion over Perimenopause and Menopause. We talk through all the stages of the female reproductive Hormone Loop--and there are way more than we've been told. A true understanding of women's health starts here!

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This episode was produced and edited by Erin Stein. Music: “All We Live For (instrumental)” by Wolfclub licensed through Audiio.com. Intro and outro edited, and video created, by Ian Mayer. The Savvy Patient logo by Amanda Spielman. 

We take a moment to remind you that while this is a medical discussion, it is not providing a diagnosis or treatment or any medical advice. The only way to get a diagnosis, treatment or medical advice for your particular condition is through a discussion with your doctor.

TRANSCRIPT

00:00 intro

00:33 Lady Cycles and Biological Clocks

08:27 Stages 1 and 2: Pre-Puberty and Puberty

13:53 Is Puberty Earlier?

19:02 Stage 3: The Reproductive Years

22:07 Periods.

31:51 Stage 4: Perimenopause

37:57 The Perimenopause to Menopause Transition

42:33 Stage 5: Menopause

45:30 What About Men (and the Whales)?

Erin Stein: Welcome to the Savvy Patient. Gillian and I were just talking about how she was suspicious very early on about Theranos, but that's not what we're talking about today.

Gillian Goddard: No, even if I am dressed like Elizabeth Holmes.

Erin Stein: She's got a black turtleneck on, so I was teasing her a little bit. But today, everyone's favorite topic, lady cycles, which is my term that I've now coined.

Gillian Goddard: Yes. It is a lot nicer than menstrual cycle.

Erin Stein: Yeah, I don't like “menstrual.” There's a lot of words I don't like related to these topics.

Gillian Goddard: Yes, glands. Moist. Moist and plump. Yeah.

Erin Stein: Glands moist is. I don't like these things. I don't like it. I mean, even puberty is like, I don't know. We came up with the worst words for all of these things. I took Latin in college, so I am happy to blame Latin. 

Gillian Goddard: And Greek.

Erin Stein: Yeah. So, this episode is for everyone who has...A womb or everyone who has ovaries? I don't know Gillian, what's the definition?

Gillian Goddard: Or someone who once had a womb and ovaries.

Erin Stein: Okay, we all hear about something called perimenopause. We all hear about something called menopause first. Now we hear about perimenopause. What are these things? What does it mean? Is it a death sentence? Which I think was the vibe for a long time.

Gillian Goddard: Yeah.

Erin Stein: You know when you see these things on Instagram where they show photos of TV characters from the 90s like when we were kids and women in their 40s look like how we picture people in their 90s now?

Gillian Goddard: Yes.

Erin Stein: Like the actual age of the Golden Girls seems not that old now.

Gillian Goddard: I know, What's-Her-Face Archie Bunker's wife was like 45.

Erin Stein: Yes. Yeah. And you're like, wait, what? So yeah, so we're going to talk about lady cycles. We are ladies, so we are qualified. We are both qualified to talk about this. Gillian more so to be fair, as the doctor between us. I have personal experience. Yes. Thank you. As many of our listeners do.

Gillian Goddard: Yeah. Yeah.

Erin Stein: But we will break down the basics because shocker, no one ever does that for you. No one does. And as a side note, because I feel like it's related, again, I do not have children. Gillian has multiple children. Yup, so many. And I think that when she was having kids and all my other friends started having kids...I realized they would tell me stuff and sometimes I think people were more comfortable telling me things than telling other moms because other moms all have, it seemed no offense to moms in general, but you all seem to have opinions about things based on your personal experience. Since I didn't have any personal experience, I had no judgment about anything related to giving birth. And so people would tell me things and I'd be like, my God, that happens? You were one of them in particular. You were telling me the condition you were in when you went home from the hospital. And I was just like, what? No one tells you that. No one prepares you for any of this.

Gillian Goddard: No. No. No. Take all the mesh shorts when you leave the hospital.

Erin Stein: Yeah, yeah, see? That. So I feel like perimenopause and menopause is very much like that. You hear it, you know it's coming, but it's a surprise.

Gillian Goddard: But it's a surprise. The lived experience is a surprise.

Erin Stein: Surprise, but we would like it to not be quite so surprising.

Gillian Goddard: Because these stages happen to everyone and so and sure everybody's experience is different but there are some commonalities and there are some ways to sort of prepare yourself.

Erin Stein: Yes. And everyone again, everyone with these particular organs, glands.

Gillian Goddard: Yeah. Yeah. And organs. Yeah.

Erin Stein: They're both. They're both. Listen to our last episode if you want to understand that. But like everyone who had those is going to go through this transition and there will be variables. You know, some women have had a hysterectomy, some have had breast cancer like me, like there are things affecting it, but all of our bodies go through this transition. So it is, there are some basics that...

Gillian Goddard: Indeed.

Erin Stein: Be good to know and I think we should just start with the fact that this transition is not a, it's there's not like a switch that goes on or off; it's not like today I'm fine and a month from now I'm menopausal it doesn't...

Gillian Goddard: So true. I think, and that's true of other stages too. Puberty, for example, everybody's favorite stage of life. It also doesn't happen overnight. I, sadly, no, don't we wish.

Erin Stein: No, sadly no.

Gillian Goddard: I think you have to think of the life cycle like a biological clock.

Erin Stein: We talk about a biological clock.

Gillian Goddard: Yes, but not that kind. Not the when Harry met Sally, Carrie Fisher at the Boathouse clock. Not that kind. Think about it like an old analog clock. The hands don't suddenly just appear at different...

Erin Stein: Not the one that never ticked for me.

Gillian Goddard: Parts of the clock, they gradually smoothly move around the clock. And sure, some stages might be bumpier than others, but our hormones and where we are in life are always shifting and always changing. But some parts are just a little more dramatic than others.

Erin Stein: And actually, I think you just touched on one of the biggest psychological issues with perimenopause and menopause, at least, and I will speak from my experience because you grow up, right? Like you're an adult and you think, okay, I figure I finally figured this out. Like, okay, here's the body I have. Here's whatever medical conditions I'm dealing with. Like, got it. I'm good. And then all of a sudden...All of that's off the table again. Suddenly you are changing all over again. And it really is in my mind, like a second puberty while not as, I mean, there are external indications, it's not as dramatic externally as puberty, obviously, but it is very much a physical life change like puberty. And we are not prepared mentally for this. I wasn't.

Gillian Goddard: And then things change, yeah. And, and depending on whether you have daughters or not, you might be experiencing it like while there's someone going through puberty in your house. So much fun. It's like double mint gum.

Erin Stein: Double the fun. Okay. Okay. So let's, let's go...Let's start at the beginning and break it down for people. Stage one, you are a child.

Gillian Goddard: Pre-puberty. These are kids. You're a kid. From a reproductive hormone point of view, there's nothing doing. Boys and girls are hormonally identical at that stage.

Erin Stein: But then, stage two.

Gillian Goddard: Puberty everybody's favorite...Pretty much, pretty much everybody goes through puberty.

Erin Stein: Everyone goes through here and I have to say mine really wasn't that bad because it was delayed frankly. I didn't start my period until very late which I was totally fine with.

Gillian Goddard: But there's a lot happening before you actually start your period. And it starts happening a ways beforehand. 

Erin Stein: You start to smell bad.

Gillian Goddard: So, you start to smell bad. That can happen really early. Some kids just stink. I say that I have one myself who's just a stinker. What are you going to do?

Erin Stein: I think you're going to bathe them. That's what you're going to do. You're get them some soap.

Gillian Goddard: It only helps so much. So yeah, so puberty is actually two separate processes. Adrenarche, which is the maturation of the adrenal loop or the adrenal hormones. This is why we smell and grow hair and get acne. And gonadarche, which is a horrible word. That is the maturation of the reproductive loop to get you ready to make more humans. And this is sort of what we classically think of as puberty from a like a reproductive point of view. It, you know, it involves your first period and breast development. So, so most girls...The first sign that they are in puberty is they develop breast buds, which are like frozen peas underneath the nipple. They can be oddly painful and they stick out at everything. Like you can see them like a hundred yards off. And so there's this very visible sign that a kid is entering puberty that precedes your first period by like two, two and a half years. And then you know you're done with puberty when your periods regulate. So, a fully adult woman will have regular cycles. That are ovulatory, meaning that you ovulate during each cycle.

Erin Stein: I'm going to correct your fully adult description because their brain is not fully adult at this point.

Gillian Goddard: Okay, their fully adult, fully mature reproductive system. Yes, myelination of the brain is still occurring. Yes, that's fair.

Erin Stein: Reproductively. For many, many years to come, in most cases. Reminder, your brain's not done until your 20s. So, I think that is a point that we don't think of very much, even though we recognize that BO and hair and all that stuff comes, that it's actually two different hormone loops happening at the same time.

Gillian Goddard: Yeah.

Erin Stein: So actually that's interesting because we think of puberty really as purely reproductive, but it is not. Generally speaking, we think and talk about puberty like a horrible, horrible time. And I have even during this podcast already.

Gillian Goddard: Yeah, yeah, we have lots of feelings. It's like we have a collective PTSD about puberty. And it's kind of funny because it's so normal. Everybody has it. And yet we have collective PTSD about it as like a society.

Erin Stein: Well, I think as a society we do and I, and I think everyone has it, but women in particular have been historically shamed for having a period at all. It's been used to separate women is what I'm going to say.

Gillian Goddard: Yeah, it has, it has. And I think that...There's a lot that happens around sexualization and puberty as well that is not appropriate given that we're often talking about 12- and 13-year-old children.

Erin Stein: That is not good. Yes. Just because these processes are getting up and running does not mean every kid is then running around wanting to have sex all the time. And I think that's also a little bit of a misconception. And adults talk about it too much around children of this age. It's my opinion.

Gillian Goddard: Yes, I think that's probably correct.

Erin Stein: But it does tie into something that I do think people are concerned about...Is puberty happening younger? Yes or no?

Gillian Goddard: Yes, particularly in girls. But it is a little bit of an interesting shift. So, breast-bud development has shifted earlier by something in the neighborhood of like a year to a year and a half. The age at which a girl gets her period has only shifted earlier by about six months. And so puberty has actually gotten longer. And there's lots of theories about why this is case. No, none of those theories has been proven. Some of it certainly is nutritional because while we talk about this as being a phenomenon of like the last generation of kids, it's actually a trend that's been going on since the mid 1800s at least. And one of the big things that has happened from a public health point of view during that time, particularly in the developed world is that we went from hunger and starvation and food insecurity to most people having the food and nutrition that they need. And so certainly that's probably a factor. We think that a hormone called leptin, which is related to hunger and satiety, actually has effects on sort of triggering the hypothalamus to trigger the start of puberty. So that's certainly the fact that people are better nourished today on average is probably a factor. People have extrapolated on that. So now we have, now our problem is not as much food scarcity in many cases, but too much. Food and too much of the wrong foods. And so there is a lot of discussion about whether childhood obesity might play into this trend as well. There's also some concern that endocrine disrupting chemicals, EDCs, may actually be acting directly on the hypothalamus. Very difficult to study for a number of different reasons. But that may be a factor as well. And there are people actively trying to understand this trend and why it's happening.

Erin Stein: What about growth hormones in your milk? Because I feel like that was a popular; popular is not the right word, but a scary thing that was talked about and publicized and...

Gillian Goddard: I mean, it's probably not great to be consuming all these things in our food supply. But we don't fully understand the role that they play.

Erin Stein: Alright, fair enough. I actually am surprised that it's only six months to a year data-wise because I think anecdotally people feel like it's a couple years earlier, but that might be due to just the fact that we're talking about it now and we certainly did not talk publicly about when young girls were entering puberty that much.

Gillian Goddard: Yeah.

Erin Stein: In times gone by and I would guess that there were always some girls who got who went through puberty at the age starting at the age of nine or eight or some other seemingly shockingly young age.

Gillian Goddard: Yeah. Yeah. Yeah, no, it has, I mean, there's always been a huge variation in what's considered normal. And so, yes, there are always going to be early bloomers and late bloomers.

Erin Stein: So, what is the normal, if there is a normal age range?

Gillian Goddard: We usually talk about average. So girls will develop breast buds sometime between the age of eight and 12, which is again, a big window. If a child does not develop breast buds by the age of 12, that's when we worry about delayed puberty. And then if kids are developing breast buds earlier than eight or nine, then we would be concerned about precocious puberty or early puberty.

Gillian Goddard: The age right now of the first period is around 11 and a half and it was just over 12 in the past. So that's sort of typically what we see. There's also something called stalled puberty So if you develop breast buds and don't have a period within four years, that's considered a stalled puberty. Usually, it's two to two and a half years from breast buds to period, first period.

Erin Stein: So, stage one, pre puberty Stage two, puberty. All right. Stage three.

Gillian Goddard: The reproductive years.

Erin Stein: I like that it's only defined by reproduction.

Gillian Goddard: Yeah, well, I didn't name them. It's not defined by the fact that you have to reproduce. It's defined by the fact that you are able to reproduce.

Erin Stein: I know, I know, and I know that's what we're talking about. Okay, so what this is essentially It starts after beauty I mean this could essentially be when you're 13...

Gillian Goddard: Yeah, so no, no. So, when in the first few years after you get your first period, most girls will take some time to settle into a regular cycle where she's ovulating every single month. You are in the reproductive years once you are having a regular period that's ovulatory and or we've figured out why you're not, but we'll get to that in another episode. So basically we say from the time that your period regulates until you're about 45, you should have a regular period every single month unless you are pregnant or using hormonal contraception.

Erin Stein: Or you're an Olympic athlete.

Gillian Goddard: Nope, you should still be having a regular period every single month. So, we used to think that women who were athletes, that it was just a function of increased activity, that people...

Erin Stein: Ooh, interesting. I'm going to say we thought it was a function of they had muscles like men.

Gillian Goddard: So, except for that we thought that it was normal for ballet dancers to have this too. That they, that if you were super athletic that you would, that it was normal for you not to get your period. Turns out that if you are properly fueling yourself for the exercise that you are doing, you should still be getting a period.

Erin Stein: Okay.

Gillian Goddard: What is actually happening if you stop having a period due to intense physical activity is that you have something called relative energy deficiency syndrome or REDs.

Gillian Goddard: And it basically means that you're not fueling your body sufficiently for the exercise that you're doing.

Erin Stein: This is amazing, this is like myth busting happening.

Gillian Goddard: It is, it is, and it's an important myth to bust because if you are not properly fueling your body and you're not getting a period, you do not have the estrogen that you need to build strong bones and it can put you at risk for osteoporosis later. So, it's really critical, it's really critical. 

Erin Stein: That seems very important.

Gillian Goddard: So basically you should be getting a period every single month from the age of about 16 to 18 all the way until you turn 45ish and maybe even beyond.

Erin Stein: Let's discuss your period that, no, not yours personally unless you really want to...

Gillian Goddard: Mine or periods in general?

Erin Stein: How do know your period is good? It's happening the way it should be happening versus it's not.

Gillian Goddard: So, a normal period for an adult woman is between 21 and 35 days long from the first day of one period to the first day of the next period. It doesn't vary more than seven days from one cycle to the next. So you're, you know, if your period is 30 days and then it's 32 days and then it's 28 days, that's fine. If your period's 24 days, then it's 45 days, then it's 32 days, that's not regular. There is no length of time that is too short. So if you only bleed for a day, lucky you. But if you are bleeding for more than seven days, that's considered to be too long. There is no amount of bleeding that's considered too little. But if bleeding is impacting your daily functioning, it is too much. Your period should not be keeping you at home, not able to do your regular activities.

Erin Stein: What about symptoms that come along with having your, you know, cramps was something I used to experience. I took birth control for many, many, many years, so I don't feel like I ever really had the mood shifts like many women describe, although perhaps people around me would disagree. I don't know. But there are many things that seem to come with this fun time that we have once a month.

Gillian Goddard: So most women have symptoms that are typical of their period. We call this premenstrual syndrome or PMS. So, cramping is common. Fatigue is common. Food cravings, especially carb cravings, are common. That's why people joke about women wanting chocolate all the time. Certainly, mood changes are quite common. PMS exists on a spectrum. Some people don't have much PMS. Some people have lots of PMS. If your PMS is extreme, and again there's no hard and fast line. But if you have severe symptoms and you have mood symptoms like depression, anxiety, irritability, then we call that PMDD or premenstrual dysphoric disorder. And that can happen at any time. Like women can experience that as teenagers. They can experience it in their 20s and 30s. But women who've had very little PMS their whole lives can suddenly in their 40s develop PMDD it is basically your body's response to a high level of progesterone that then just kind of tanks.

Erin Stein: Many women probably put up with too many symptoms or side effects, if you'd like to call them that, during their period because we've always been taught whether directly or indirectly, that that's just the deal. You're just going to be miserable and everyone should just stay away from you for a couple days and look out. PMS is here. I think if it's that bad that people need to stay away from you, you should be going to the doctor.

Gillian Goddard: Yeah, no, I think that's right. I think my threshold for recommending treatment for PMS, and there's a few different forms that that can take, is when it's impacting your day-to-day life. If you have to hide in your room from all people for two days, that's not okay. If you can't get out of bed because you're having severe cramps for however long ever, that's not okay. Like these are symptoms that can be addressed and they can be addressed at any age. So, they can be addressed in teenagers, they can be addressed in women in their 20s, 30s, 40s, 50s.

Erin Stein: Yes, please don't let the teenagers suffer. Let's give them a better life.

Gillian Goddard: I know, I know. Nothing, nothing breaks my heart more than a teenager suffering from PMDD or bad PMS.

Erin Stein: I took a birth control pill for 20 years basically, because I was not interested in having my period, I never wanted to have children. I love children. I love Gillian's children and many other children. That sounds weird the more I say it. But I just never felt that biological clock ticking. And so, the last thing I wanted to do was have an accidental child. Like, so yes, I was on birth control for a long time. Also, because when I was on birth control, it regulated things and that seemed to be going well. My PMS was not much, almost non-existent. And...

Gillian Goddard: Non-existent probably.

Erin Stein: I could skip my period. I didn't skip it 100% of the time. It would be like every three or four months. So, I would have a period like three or four times a year, four times a year usually. Some people think that I'm crazy for doing that and that it's wildly unnatural to not have your natural period on a monthly basis. I obviously don't care and disagree; I don't feel the need to bleed into my underwear once a month. But perhaps you could weigh in on the natural versus unnatural perspective that some people bring to this discussion.

Gillian Goddard: I mean, if you aren't taking a birth control pill or you don't have an IUD, you should be having a period. It serves a biological purpose in that situation. It is sloughing off the uterine lining and starting the cycle over again. Fine. If you have an IUD or you're taking birth control pills, you do not have to have a period because it's not serving a biological purpose in that case. In fact, when they developed birth control pills. The reason that they developed them the way they did to mimic a natural cycle is because they thought that they it would make the pills more appealing to women and to the Catholic Church. Um, the Catholic Church has still not gotten on board 70 years later.

Erin Stein: Let's take a step back ladies because I feel like I went most of my life without realizing that the period you have when you're on birth control is not a quote unquote real period.

Gillian Goddard: It is not a period; it is a withdrawal bleed. Yes. 

Erin Stein: Gillian, please explain.

Gillian Goddard: So, a period is when you have a menstrual cycle where you mature an egg and build a uterine lining, you ovulate, that egg passes, doesn't meet up with a sperm and get fertilized and passes out of your body and your progesterone levels and you slough off the lining and start the process over again. A birth control pill works as a contraceptive because it prevents ovulation. It shuts down the entire reproductive loop and just gives you a steady dose of estrogen and progestin, which is just a synthetic progesterone. All the days that you take the active pills...

Gillian Goddard: And then when you start taking the sugar pills, your progesterone and estrogen levels drop and you slough off whatever lining has been built up. But you don't build up much of a uterine lining when you're taking a combination of estrogen and progesterone together over time. And so, what you're having is a withdrawal bleed because it's a bleed in response to the withdrawal of the hormones. And it doesn't serve a biological purpose. And so, you could literally take birth control pills back-to-back and never have a period if you wanted to. Some people get some breakthrough bleeding with that...

Erin Stein: So, first of all, what the actual fuck? That they built in a fake period to birth control pills?

Gillian Goddard: Yes! Yes!

Erin Stein: That upsets me. But I would go back-to-back until I would get some breakthrough bleeding eventually. I couldn't do it forever with the one I was taking. There is a misunderstanding that it's unnatural to not have it. But if you're not planning to grow a baby in there...

Gillian Goddard: Right, right, right, right. And that's true for a lot of women. That doesn't serve another purpose. And in fact, if you're not planning to grow a baby in there, it's best not to grow a baby in there. We are lucky to have effective contraception.

Erin Stein: Yes, I think so too. Should we get to the fun part? Stage four, just to recap, since we've been meandering a little bit, stage one, pre-puberty, stage two, puberty, stage three, the reproductive years, or in my case, the non-reproductive years. And stage four, perimenopause. Spoiler alert, it has more stages within it.

Gillian Goddard: So, like everything, you don't just one day wake up in perimenopause, contrary to popular belief. There's actually a bridge from the reproductive years to the perimenopausal years, and it is called the late reproductive stage. And that's the first, and that is something many, many people have no idea about. There are doctors that don't know about the late reproductive stage. But it's super important because if you go to your doctor and say, I think I'm in perimenopause, I'm having all these symptoms, and then your doctor will ask you one question, are your periods regular? And you will say yes, probably, if they are, and your doctor will say it's not perimenopause, and you'll leave feeling frustrated because you still have symptoms, whether your periods are regular or not. And that is the late reproductive stage. Most people enter it between the ages of like 37 and 45. And it is a time when things like PMS can get much worse. People can develop new PMDD during the late reproductive stage. All the hormones are still rising and falling the way they always did. It's just they're rising higher and falling lower and those big hormonal swings while still organized can make us not feel amazing. Eventually periods become irregular. So the length of your cycle from the first day of one period to the first day of the next will start to vary by more than seven days. But you'll still be having a period at least every two months and that is called early perimenopause.

Erin Stein: So late reproductive stage shifts into early perimenopause, technically because your periods become irregular. That's the difference. Okay.

Gillian Goddard: Exactly. That's exactly right. And your period should not become irregular before the age of 45. If your periods become irregular before age 45, you want to see your doctor. There may be other reasons why.

Erin Stein: You may need to rewind for our definition of regular to irregular.

Gillian Goddard: People think that women like march through all these stages in an orderly fashion, but some researchers in Seattle, the Seattle Midlife Women's Health Study found that actually half of women, half of women, seesaw back and forth. Between the late reproductive stage and early peri menopause. So, you can go have regular periods, then have irregular periods, then have regular periods again, then have irregular periods. And that's totally normal in your mid to late 40s.

Erin Stein: It's so much fun.

Gillian Goddard: It is. You want to know the other part that's super fun is that the length of the late reproductive stage and early perimenopause can vary wildly from almost non-existent to like a decade. So it's not very predictive.

Erin Stein: Predictable. What is the reason for so much variability? Like, I believe we are all different and our bodies all have different things going on. Certainly, by that age, from all factors, genetics and environment and what we eat and everything else, but that seems like a wild range of variability...

Gillian Goddard: What we know most about is the age that a woman is at her last menstrual period. And there are a number of factors that affect that, but genetics seem to be the biggest. Smoking is the other biggest, which makes it very difficult for most of us to figure out when we're going to have our last period because everyone like our mothers and our grandmothers all smoked. So, you're in early perimenopause, your periods are irregular. Then you enter late perimenopause. Late perimenopause means that you go more than 60 days without having a period. And the one thing that's super helpful about this is that most women who go more than 60 days without having a period because they are in late perimenopause will have their last menstrual period in the next 12 to 36 months.

Erin Stein: So the end is in sight.

Gillian Goddard: The end is in sight. The end is in sight. Then you have your last menstrual period, but you don't know it's your last menstrual period because it's not like it's like, this is it. We're done. Bye. The last egg isn't like letting you know it's the last egg on its way out. 

Erin Stein: Toodle-loo! I'm out.

Gillian Goddard: Yeah, they don't. Yeah, there's no there's no indication. It's not different from any of your other periods around this time, but it's your last menstrual period. And then you transition into stage five.

Erin Stein: Stage four, perimenopause has three stages, late reproductive stage, early perimenopause, late perimenopause, and then we finally reach stage four...

Gillian Goddard: Yes, but menopause is subdivided into two stages and one of those stages is subdivided into two stages.

Erin Stein: My god. Why?

Gillian Goddard: Because each stage has its own flavor.

Erin Stein: Now that we've walked through the differences in the timing of your period, guess that explains the stages in perimenopause, what is the point of having all these different stages mapped out?

Gillian Goddard: Yeah, I think a couple of things. One is it helps us to understand what women experience when. So, it helps with research to know all these stages, right? If you can pinpoint where a woman is, that's important. So, we know things like, so the study of women's health across the nation or SWAN, if you will.

Erin Stein: Fair enough, that seems important.

Gillian Goddard: Is a big longitudinal study. It's a great study because it actually includes women of color along with white women in a very intentional way that makes it helpful. In SWAN they really pinpointed when different symptoms happen. So like in the late reproductive stage, the symptoms tend to be very much about worsening PMS, some mood changes, that kind of thing. Whereas the late perimenopause and early menopause, which is the first stage of menopause, tend to be when vasomotor symptoms, so hot flushes and night sweats really ramp up. Then menopause is when sort of a lot of the genitourinary symptoms start to pop up. So vaginal dryness and those type vaginal atrophy. 

Erin Stein: More words I don't like.

Gillian Goddard: I hear you. Giving us all these stages allows us a framework in which to sort of understand how many women experience the menopausal transition.

Erin Stein: I know I recently asked you this question legitimately, we have a menu of symptoms or as we call it on Substack, a menu of misery that all these things that you could be experiencing, hopefully you're not experiencing all of them. And if you are, you really should go see your doctor for some help.

Gillian Goddard: Yes.

Erin Stein: But perimenopause, menopause, like, it's the, to me, it's all the same basket of crap that you might be dealing with, but it sounds like there are some... markers for when you're more likely to have these things.

Gillian Goddard: So, you can have all of these symptoms sort of throughout the menopausal transition, but most women will experience certain symptoms at certain times. And I think that that's helpful because...You can have a little bit of a better idea of what to expect.

Erin Stein: Little bit better.

Gillian Goddard: Look, there's exceptions to every rule and one person's experience may not be what the textbook experience is. It's very unlikely to fit the textbook experience exactly, but knowing like, okay, this is when I'm most likely to experience this, that, or the other, I think is helpful. And to know, because we're talking about something that goes from when you're 40 to when you're 60, to know that it's unlikely that you will have two solid decades of misery is also, I think...

Erin Stein: That is a silver lining. A silver lining indeed. Perhaps, hopefully, the textbooks will become better because at some point we will also talk about how little data has been collected for such an important and, as you just noted, long period of time in half of the population's life.

Gillian Goddard: Right? Half the population experiences a transition over two decades and we know very little about it. In fact, those stages that I just talked about, those were developed in 2001 and actually revised after that. But yeah, 2001. Mean, I'm going to show my age here, but I don't feel like that was that long ago.

Erin Stein: No, because for us it was like five years ago.

Gillian Goddard: Menopause has two stages. The first stage is broken into two stages. So, so menopause is broken down into early and late. And early is broken down into the first part, which is like the one to three years after your last menstrual period. And then the next part, which is like the next five to eight years. So why, why is it broken down like that? Because...

Erin Stein: God, alright, okay.

Gillian Goddard: The first part of early menopause, A, you don't know you're in menopause, because you don't know that you had your last menstrual period until you don't have a period for a year, for 12 months. And B, your hormones are still fluctuating quite a lot. And so the symptoms during that time period are much more similar to the symptoms of late perimenopause than to the rest of menopause. And so that's important too.

Erin Stein: Does that mean that when you get to late-stage menopause, you don't have symptoms anymore? Typically. Typically.

Gillian Goddard: Typically. Some women will, but it's much less, much, much, much less common. And the most common symptoms in late menopause are actually the genitourinary symptoms. And the good news about that is those symptoms we know how to treat and treatment is safe for everyone, including women with breast cancer.

Erin Stein: Ugh. God. Okay, well that's good. That is another silver lining. And then, so are you then just in late-stage menopause the rest of your life or do you move on into some unlabeled stage? That's just it. That's it. Okay.

Gillian Goddard: I do my best for you. Yep. Nope. Nope. Nope. That's it. So it could be, depending on how long-lived you are, it could be your longest reproductive stage of your life. And many women find that once they kind of get into that stage, they have like a lot of things that they worried would not go away do. So...

Erin Stein: That's true, actually.

Gillian Goddard: You know, a lot of the cognitive symptoms that women experience during the perimenopausal transition, brain fog, word finding difficulty, lack of focus, a lot of women find that these symptoms get much, much, much, much better and then they're like ready to like for a renaissance. They're ready for their second act.

Erin Stein: I look forward to that. I look forward to the end of the period in multiple meanings of that word. This is quite a thing that women, those of us with certain organs and glands go through. Do men do anything after puberty? Like why is this so unfair?

Gillian Goddard: So, men's reproductive systems are much simpler. Much simpler.

Erin Stein: I'm not going to take the low hanging fruit and I'm not going to do it.

Gillian Goddard: So, men continue to produce sperm and testosterone from puberty on. They do experience a gradual drop in testosterone and sperm production starting in midlife. So, starting in the late 40s or 50s, but it is gradual. The other thing is that men have a diurnal variation in their testosterone levels. 

Erin Stein: I don't know what that means. You're going to have to define that.

Gillian Goddard: To speak some English. So, testosterone levels in young men are high in the morning and low as the day goes on. This is very pronounced in young men. And as men age, it flattens out. So, by the time somebody's 80, they have very little change in their testosterone over the course of the day. So those are the main changes that men experience. Men can have babies when they're 80. Charlie Chaplin had a baby in his 70s.

Erin Stein: Yeah, he didn't have the baby. He donated some material. Let's be clear. I guess, yeah, they're not having to grow the entire other human...

Gillian Goddard: No, he fathered a baby. They don't grow the... Yeah. Although, we are one of the only species who experiences menopause.

Erin Stein: I do think that's interesting because whales, right? Some whale species. And to me, whales are intelligent, do have culture, do have society. We should never be killing whales. We should be trying to figure out and talk to them.

Gillian Goddard: There's a couple, there's some species of whales and then the other is a subset of chimpanzees has been shown to experience menopause, which makes sense because we're very genetically closely related to chimpanzees. It's actually more surprising that most apes don't experience menopause.

Erin Stein: Yes, it makes sense that they would. I do find that more surprising because some of them are long-lived.

Gillian Goddard: Yes, some of them are long-lived and when humans had shorter lifespans. It's not that no one was living to be 80 or 100. It was that the average lifespan was shorter because people were dying of disease like infectious disease earlier in life or getting eaten or you know, whatever. So...

Erin Stein: Yeah, saber tooth tiger.

Gillian Goddard: So, it's not that the human lifespan has expanded so much, it's just that more people are living more of that lifespan because of, you know, modern medicine.

Erin Stein: I think, well, you know, I think that's interesting because I don't know that we think about it that way.

Gillian Goddard: No, you know, so every woman goes through menopause, it's incredibly well preserved. So, among humans. So it must serve some very important function for it to be so well genetically preserved or it wouldn't happen in every single woman. The theories are very much around nurturing and helping the grandmother hypothesis.

Erin Stein: Well, the grandmother hypothesis to me it's not even nurturing, it's just doing everything that needs to be done, frankly. But then what about the old men? What are they doing?

Gillian Goddard: Try not to think about it too much.

Erin Stein: Fair. I don't know that we have anything else to offer other than Gillian's renaissance that she promises you at the end. We're all hoping for that.

Gillian Goddard: I'm looking forward to it.

Erin Stein: But we have what, 15 more years until we get there?

Gillian Goddard: No, 12.

Erin Stein: Well, okay, so that's so much better. All right. Well, Until our next...Period...Together.